Provider Demographics
NPI:1629073465
Name:FERRARA, ERIC D (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:D
Last Name:FERRARA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4214
Mailing Address - Country:US
Mailing Address - Phone:770-228-1010
Mailing Address - Fax:678-692-0242
Practice Address - Street 1:614 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4214
Practice Address - Country:US
Practice Address - Phone:770-228-1010
Practice Address - Fax:678-692-0242
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013416204E00000X, 261QD0000X, 1223S0112X, 1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA178058507BMedicaid
GA178058507AMedicaid
OHU96963Medicare UPIN